Access to Alcohol

Alcohol availability, measured in terms of geographic density of alcohol-sales outlets, is linked to specific patterns of alcohol-related motor vehicle crashes in communities. To curb alcohol-related problems such as violence, traffic crashes, and drinking and driving, community advocates often focus on reducing alcohol availability through modifications of zoning laws and licensing requirements. In developing interventions and policy activities to reduce alcohol availability, community policymakers should assess the effects of outlet density using an adequate community “biogeography” of the interrelationships among drinkers, their drinking environments, the locations of alcohol outlets, and the locations of alcohol problems. Communities also should consider that the economic development of downtown areas, which is often accompanied by the rapid growth of alcohol outlets, is likely to affect the incidence and prevalence of alcohol-related problems in surrounding areas.

forth), and the number of alcohol out lets per kilometer of roadway (i.e., geo graphic availability) (Gruenewald 1993).Alcohol outlets may be State controlled or privately owned businesses, and alcohol may be consumed on the premises (e.g., at bars and restaurants) or purchased for later consumption off the premises (e.g., at grocery, convenience, or liquor stores).These two types of outlets are known as onpremises and offpremises establishments.

THE GEOGRAPHY OF AVAILABILITY AND ALCOHOL RELATED PROBLEMS
Most recent studies conclude that a relationship exists among alcohol availability, alcohol use, and alcohol related problems (Gruenewald 1993).One recent study found that a ban on Sunday alcohol sales in a Georgia community appeared to reduce the in cidence of drinking and driving on all days (Ligon and Thyer 1993).A study of changes over time in alcohol sales, the incidence of crime, and drinkers' involvement in the criminal justice system in England and Wales sug gested that easy access to alcohol may be implicated in a wide range of crimes (Ensor and Godfrey 1993).In another study, the elimination of a prohibition against wine sales in New Zealand grocery stores was found to increase such sales (Wagenaar and Langley 1995).Likewise, the elimination of retail wine monopolies in five States was found to increase wine sales (Wagenaar and Holder 1995).Given the strong relationship found between alcohol sales and problems such as alcoholrelated crashes (Gruenewald and Ponicki 1995a), cirrhosis mortal ity (Gruenewald and Ponicki 1995b), and suicide (Gruenewald et al. 1995), increases in alcohol sales may be related to considerable increases in these problems.
Scribner and colleagues (1994,1995) provided the first evidence sug gesting statistically reliable associa tions at the local level between the number of alcohol outlets (i.e., outlet density) and the frequency of motor vehicle crashes and rates of violent assaults.Although their studies had a number of methodological and statis tical problems, 1 the researchers did demonstrate, based on data they col lected in 72 contiguous cities in the Los Angeles basin, the feasibility of performing extensive community based geographic analyses of alcohol availability and associated problems.Scribner and colleagues demonstrated significant positive relationships be tween measures of outlet density and alcoholinvolved traffic crashes and rates of violent assault.Although motor vehicle crashes primarily were associ ated with drinking in onpremises establishments, rates of violent assaults were related to greater densities of both on and offpremises establishments.
Parker and Cartmill (1996) also demonstrated statistically significant links between geographic availability and rates of violent assault across census tracts in a small California com munity.These authors found that rates of violent assault were related posi tively to the density of offpremises outlets.Alaniz and colleagues (1996) generalized this work to several cities, demonstrating an association between youthful violence and the geographic availability of alcohol.Each of these studies presumed the existence of a geographic link between the availabil ity of alcohol and alcohol problems (e.g., that individual drinkers pur chased or consumed alcohol in specific locations, then drove elsewhere and subsequently were involved in drinking related crashes), and each presented data largely supporting the validity of these presumptions.
In a study of the connections be tween alcohol sales and the preva lence of drinking and driving in Perth, 1 Scribner and colleagues measured alcohol availability in terms of outlets per person.However, measurements in terms of outlets per geographic unit better reflect a consumer's ease or difficulty in obtaining alcohol.Analyses of fixed geographic units usually are interrelated (i.e., have a great deal of spatial dependence) and thus require specialized statistical tech niques for analysis.
Australia, Gruenewald and colleagues (in press) demonstrated that incidence of drinking and driving (both involv ing and not involving crashes) could be predicted by the type of establish ment that offered alcohol for sale and the volume of alcohol sold to the driver.Specifically, outlets that sold the greatest quantity of alcohol, par ticularly nightclubs serving beer and spirits, were likely to produce the largest proportion of drinking drivers.

A Closer Look at the Geography of Alcohol Problems
This research has established that the availability of alcohol is linked to specific patterns of alcoholrelated motor vehicle crashes in community settings.To better clarify the link be tween the number of alcoholic beverage outlets and the incidence of alcohol related crashes in four California com munities, Gruenewald and colleagues (1996) studied the relationships be tween traffic crashes and several other geographic factors, including environ mental, demographic, and drinking vari ables and measures of outlet density.
The researchers selected traffic crash measures that represented specific alcoholrelated events (e.g., singlevehicle nighttime [SVN] crashes, which are most likely to involve al cohol) (Holder et al. 1995).Environ mental variables were those that described the general ecological fea tures related to traffic patterns in the communities (e.g., average daily traffic flow, crossstreet counts, and total number of intersections).Demo graphic and drinking variables were obtained from a general population survey of adults and described popula tion characteristics and factors rele vant to drinking (e.g., income, average age, frequency of drinking, and aver age drinking levels).Measures of outlet density represented the physi cal availability of alcohol by outlet type measured over a metric scale representing use of space (i.e., the number of bars, restaurants, grocery, and liquor stores per kilometer of  roadway).Using specialized statistical techniques (i.e., geostatistical regres sion models) to correct for problems that arise in the analysis of geographic data, the researchers found that environmental, demographic, drinking behavior, and outletdensity variables were related to crash rates across all the geographic units in the study.
To ensure accurate comparison, each community was partitioned into a number of relatively small geo graphic units whose sizes generally reflected local population densities (i.e., the units were smallest in the most dense areas).The ranges of various measures in the study across these geographic units differed from one unit to another, sometimes dra matically.For example, the proportion of people who abstained from using alcohol ranged from 3 to 61 percent, unemployment rates varied from 0 to 12 percent, and outlet densities varied from 0 to 4 outlets per kilometer of roadway.(See figure 1 for examples of geographic distribution maps generated for one of the four communities.) The street map of each local com munity then was used to identify out let locations and SVN crashes within each geographic unit.By mapping both of these variables onto the geo graphic units, annual rates of SVN crashes could be related to locations of outlets within and between com munity study areas (figure 2).
The results of these data analyses demonstrated significant relationships between restaurant densities and SVN crashes both across and within the communities.Specifically, the greater the level of alcohol availability through restaurants, the higher the rates of alcoholrelated crashes across the geo graphic units of the study.Overall, 10 percent greater restaurant density was related to 1.7 percent higher crash rates.The effect of restaurant density on crash rates extended to adjacent areas as well: Rates of alcoholrelated crashes within each study area were affected by restaurant density both within those areas and in surrounding areas, demonstrating the "spreading" effects of alcohol availability in com munities.Interestingly, the positive relationship between outlet density and traffic crashes in these communi ties was found primarily for restau rants.No significant effects on traffic crash rates were found for increased densities of bars or offpremises alco hol outlets (Gruenewald et al. 1996).Restaurants appear to supply the great est proportion of drinking drivers, at least in California, where restaurants are frequented about twice as often as bars for the consumption of alcohol.
If restaurants are the type of estab lishments that produce the most drink ing drivers, restaurant density could be an important predictor of community patterns of alcoholrelated motor vehicle crashes.The distribution of restaurants As noted by Gruenewald and Millar (1996), although the three communi ties had much in common, each one implemented the access intervention in slightly different ways.The first community rapidly developed the in tervention, moving quickly to initiate bans on alcohol use in city parks, maintain current planning and zoning restrictions on alcohol outlets, and develop new planning and zoning regulations.These efforts were ac companied by restrictions on alcohol availability at public events, continued protests over problem outlets, and pre paration of a model Conditional Use Permit (CUP) ordinance (i.e., a permit for alcohol sales that is conditional on restrictions established by city or county governments).Nonetheless, during the intervention period (1995), the city council exempted the downtown area from selected CUP requirements, en abling the rapid growth of outlets for the purpose of community development.
The second community moved somewhat more slowly in developing the access intervention, receiving sup port from the city council to form an access task force and suggesting revi sions to alcoholrelated ordinances.However, rather early in the interven tion period (1994), the city council had begun considering easing alcohol reg ulations to promote downtown growth, a move supported by the local cham ber of commerce, which ultimately opposed all new CUP ordinances.
The third community was working within the context of a comparatively primitive regulatory environment.For example, until midway into the inter vention period (1995), alcohol licens es were reviewed in the State capitol, effectively blocking local representa tion at licensing hearings.When the State Alcoholic Beverage Control agreed to conduct licensing hearings in the local community, the regulatory change allowed local citizens to inter vene more effectively in the licensing process.Around the same time, the city council began to allow local police to testify in alcohol licensing hearings.The police provided official informa tion concerning problem outlets to help lobby for their closing.
Although the three communities' approaches to reducing alcoholrelated problems diverged, each community began the process in the same way: by developing a coalition and gather ing scientific support for the interven tion activities.These three brief case studies show that local communities can apply the scientific evidence sup porting the existence of a relationship between alcohol availability and alco hol problems.As a prime example, in all three communities, advocates for constraints on alcohol availability used evidence from studies such as those cited in this article to suggest that increasing the required minimum distance between outlets would be the best first step toward reducing avail ability and decreasing alcoholrelated problems.Thus, by proposing planning and zoning changes, the advocates im plemented the scientific observation that geographic outlet density has the greatest impact on alcoholrelated problems in the community.

TOWARD A BIOGEOGRAPHY OF DRINKING PROBLEMS
From the perspective of those interested in reducing alcohol problems in their communities, the physical availability of alcohol makes an attractive policy target.Unlike alcoholic beverage taxes, the location of alcohol outlets is subject to local regulation and can be closely monitored by community groups.In addition, and again unlike alcoholic beverage taxes, alterations in the physi cal availability of alcohol can have im mediate effects on patterns of alcohol use within communities and can re duce access substantially in locations where highrisk behavior is likely (e.g., in bars and restaurants near highways).Another appeal of regulating alcohol availability is that regulations affect access to all beverages sold by an out let (regardless of price) to all segments of the population (regardless of in come).In contrast, alcohol taxation takes place in an environment where beverage prices differ by orders of magnitude and the effects of a tax may be diluted by the range of beverage prices and other factors.(For more information on alcohol tax policy, see the article by Kenkel and Manning, To support community activities in reducing the availability of alcohol, much further research must be per formed.As noted in this article, the evidence for a direct link between availability, alcohol use, and specific alcoholrelated problems at the com munity level has been scant, consisting of only a handful of studies.In addition, theoretical models of the geographic relationships between availability and alcoholrelated problems are still in their infancy (see, for example, Gruene wald et al. 1996).Although the de mography and drinking behavior of local populations may differ dramati cally across geographic areas, no theo retical or empirical study exists that has examined how these geographic differences relate to alcohol problems.Researchers undertaking such studies seek to answer many questions: Are there pools of highrisk populations on which outlets draw that produce alcoholrelated problems?Are there areas in which the conjunction of high outlet density and highrisk popula tions is particularly likely to produce problems?How can the relationships between pools of alcohol users and sources of alcohol be geographically portrayed?What is an adequate theory of the processes by which changes in alcohol use and alcoholrelated prob lems occur in response to alterations in availability?To the extent that these questions can be satisfactorily ad dressed, communities be able to respond to local alcohol problems.
To support the rational development of community interventions and policy activities intended to reduce the po tentially harmful consequences of al cohol availability, the construction of an adequate "biogeography" of alcohol problems at the community level is needed.A biogeography of alcohol problems would describe the interrela tionships among drinkers, their drink ing environments, the locations of alcohol outlets, and evidence of alco hol problems.For example, in cases of alcohol dependence and heavy or binge drinking, the convergence of popula tions at risk (e.g., young to middleaged single males) and increased access to alcohol may be key to determining the geographic distribution of types of drinking problems.In the case of drinking and driving, the location of alcohol use (e.g., restaurants)-not the location of the drinker's homemay be directly related to motor vehicle crash sites (Gruenewald et al. 1996).
As another example, the combination of a youthful pool of potential drinkers and greater offpremises alcohol avail ability may determine rates of under age drinking and problems related to such use.

CONCLUSION
Many communities are confronted with serious problems regarding alcohol availability and associated alcohol related problems.Moreover, drinking and driving and the crashes that result are not limited to those areas of the community with the greatest concen tration of alcohol outlets; the effects spread across adjacent community areas that may have comparatively low alcoholoutlet densities.There fore, communities need to assess the impact of increased outlet density in broader geographic terms.In addition, communities must consider that the economic development of downtown areas, often accompanied by the rapid growth of alcohol outlets, is likely to be accompanied by rapid growth of al cohol problems in surrounding areas.
In communities grappling with alcoholrelated problems, activists will continue to pose the following central questions: "How do we prevent or reduce alcoholrelated problems in the community?"and "Are reductions in availability sufficient to reduce these alcohol problems, or are changes in enforcement and preventive education also necessary?"The advancement of theoretical models of the geography of alcohol problems and the application of methods to mapping these problems will help answer these questions and make possible more targeted preven tive interventions.■

Figure 1
Figure 1 Geographic distributions of environmental and demographic measures for one California community.The environmental measures represent general features of the community related to traffic crashes (e.g., average daily traffic flow and number of cross streets).Demographic and drinking measures are characteristic of the population (e.g., frequency of drinking, average drinking level, income, and average age).Restaurant count represents the physical availability of alcohol.Traffic crash measures refer to specific alcoholrelated events (e.g., singlevehicle nighttime [SVN] crashes).As shown in these maps, substantial geographic variation exists within the community for all measures.

Figure 2
Figure 2 Mapping the relationship of restaurant availability to singlevehicle nighttime (SVN) crashes.The street map of each local community is used to identify outlet locations (e.g., tan dots represent restaurants) and SVN crashes (represented by red triangles) within geographic units.These data demonstrate a significant relationship between restaurant densities and SVN crashes both across and within the communities.
Timeline for Intervention Activity for Three Experimental Communities in the Community Trials Project for Intervention Activity for Three Experimental Communities in the Community Trials Project (continued) NOTE: CUP = Conditional Use Permit (i.e., a permit for sales of alcohol conditional on restrictions established by city or county governments).Timeline